Cuboid subluxation in ballet dancers PETER MARSHALL,* MA, PT, AND WILLIAM G. HAMILTON, MD
From the American Ballet Theater, New York, New York
ABSTRACT
cuboid will usually yield excellent and often dramatic results in the management of this commonly overlooked affliction. A dancer (or athlete) with a cuboid subluxation will complain of lateral foot pain and weakness in push-off. The pain often radiates to the plantar aspect of the medial foot, the anterior ankle joint, or distally along the fourth ray. The dancer usually feels an inability to &dquo;work through the foot,&dquo; while moving from foot-flat to demi-pointe or full pointe. Dancing vigorously and jumping are usually impossible because of localized, sharp pain. Pressing dorsalward on the plantar surface of the cuboid is painful. The cuboid’s minimal dorsal/plantar joint play is markedly reduced or absent when compared to the uninvolved foot. Severely subluxated cuboids sometimes leave a shallow, visible depression on the dorsum of the cuboid and a fullness on the plantar aspect. Unfortunately, repeated attempts to document or confirm the diagnosis by radiographs, computerized axial tomography (CT) scans, or magnetic resonance imaging (MRI) studies have been unsuccessful because of normal variations between the cuboid and its surrounding structures. Other authors agree that this is probably caused by the minimal amount of subluxation that is present Indeed, the term &dquo;locked cuboid,&dquo; used by Hiss5 s may more accurately describe this condition. This term suggests a small subluxation that markedly reduces the normal motion in the midtarsal (Chopart’s) joint, altering the normal mechanics and the relationship between the hindfoot and forefoot. Other well-known and well-accepted conditions such as subluxations of the shoulder’ and metatarsophalangeal joints of the foot&dquo; cannot be documented on radiographs and the diagnosis must be made on the basis of the patient’s history and physical examination. Occasionally, the fourth metatarsal may subluxate on the cuboid. These subluxations can be easily mistaken for plantar subluxations of the cuboid, because the base of the fourth metatarsal almost always moves dorsally in the dancers we have seen. This diagnosis is aided by the fact that a subluxated metatarsal acts like a log floating in the water-when one end rises, the other end sinks. Thus, when the base of the fourth metatarsal subluxates dorsally on the cuboid, the head of the metatarsal will be plantarflexed (&dquo;dropped&dquo;) when compared to the adjacent metatarsals and the fourth
Cuboid subluxation is a common but poorly recognized condition. Its symptoms include lateral midfoot pain and an inability to "work through the foot." In addition, pressing on the plantar surface of the cuboid in a dorsal direction produces pain. The normal dorsal/plantar joint play is reduced or absent when compared to the uninjured side, and subtle forefoot valgus is present. Frequently, there is a shallow depression on the dorsal surface of the foot and palpable fullness on the plantar aspect of the cuboid. Documentation by radiograph, CT scan, or magnetic resonance imaging is difficult because of the normal variations found in the relationship between the cuboid and its surrounding structures. The diagnosis is primarily subjective, and must be made on the basis of the patient’s history and physical findings. Treatment requires recognition of the condition, manual reduction by a therapist or physician familiar with the condition, and followup to be certain that the cuboid remains in place. Therapists and orthopaedists involved in the care of dancers should be alert to the possibility of cuboid subluxation and be able to recognize it when it occurs.
spite of the scarcity of information in the medical literaon cuboid subluxation,’ experience with professional ballet dancers suggests that this is a common but poorly recognized affliction.’ We report the incidence of cuboid In
ture
subluxation in American Ballet Theater,
one
of America’s
premier international ballet companies. The characteristic symptoms, physical findings, and theories regarding its cause are presented, as well as a variety of manual therapeutic techniques that reduce the subluxated cuboid and subluxation of the fourth metatarsal on the cuboid. When the to this syndrome, it can be easily recognized. Patience and practice in manual reduction of the
physician is alert
*
Address
correspondence and repnnt requests
to Peter Marshall, MA, PT,
Physical Therapist, Baryshnikov Productions and The White Oak Dance Project, 111 East 14th Street, Suite 385, New York, NY 10003.
169
170
metatarsal of the uninvolved foot (Fig. 1). Dancers with dorsal subluxations of the base of the fourth metatarsal present with the same symptoms as dancers with plantar subluxation of the cuboid. They are also predisposed to capsular irritation (&dquo;stone bruises&dquo;) of the plantar aspect of the head of the prominent fourth metatarsal. Most professional female ballet dancers have dorsal callosities (&dquo;toe shoe knots&dquo;) over the dorsum of the metatarsal heads. Thus, the absence of a callus over the fourth metatarsal head indicates that the fourth metatarsal has been in plantarflexion for some time and may be a normal condition for that particular dancer, especially if she has the same configuration in the other foot. This finding alone does not necessarily rule out an acute dorsal subluxation of the base of the fourth metatarsal, but it greatly diminishes its prob-
ability. Abduction of the forefoot at the midtarsal joints predisposes an individual to plantar cuboid subluxation.&dquo; Careful inspection of the relative position of the forefoot to the hindfoot will often reveal a subtle midfoot abduction when the cuboid subluxates, in comparison to the uninvolved foot. The abducted position of the foot must be corrected or diminished to facilitate and maintain reduction of the cuboid (Fig. 2). The tendency for ballet dancers to seek the valgus position of the forefoot when on releve may predispose them to cuboid subluxation. Cuboid subluxation secondary to a sprain of the lateral foot or ankle is more difficult to detect because it is easy for the clinician to assume that the dancer’s complaints are
Figure 2. To realign an abducted midtarsal joint, the patient’s foot is positioned between the clinician’s knees, the medial foot is contacted at the distal talus and the lateral foot at the lateral aspect of the cuboid, and an adduction force is then applied by the clinician’s hand and knees. TABLE 1
Incidence of cuboid
injuries in professional dancers
because of injured soft tissues. Effusion and ecchymosis make determination of the cuboid’s joint play, or visible detection of a shallow depression, difficult. While pressing dorsalward on the plantar aspect of the cuboid may be uncomfortable to anyone with a sprain of the lateral foot, it causes severe pain in someone who has sustained a cuboid subluxation accompanying such a sprain. Lingering symptoms and disability may indicate that cuboid subluxation has occurred along with the injury. Incidence
Figure
1. The
&dquo;dropped&dquo; fourth metatarsal head.
The records of all injuries requiring physical therapy treatments in the American Ballet Theater were reviewed during two separate 3-week periods to examine the incidence of cuboid subluxations during both performance and rehearsal schedules. The records examined were from a 3-week performance season in Los Angeles during March 1986 and from a 3-week rehearsal schedule in New York City during January 1987. Cuboid subluxations totaled over 17% of foot and ankle injuries during these two periods (Table 1). There were no significant differences between the performance and the rehearsal schedules. Newell and Woodie’ reviewed the records of 3600 athletes with foot injuries and found that 4% of their symptoms came from the region of the cuboid bone. The incidence of cuboidrelated difficulties appears to be higher in professional dancers than in other athletes. This disparity is presumably due to the technical and aesthetic demands of ballet.
171
Etiology
Treatment
While Newell and Woodie8 found that 80% of cuboid subluxations in athletes occurred in pronated feet, we have not found this to be true in dancers. We found that cuboid subluxation occurred in all foot types, including cavus feet (the most desirable in ballet). A cavus forefoot can still pronate in relation to the hindfoot, and the dancers who pronate (usually to compensate for deficiencies in turnout from the hip and knee) appear to have an increased incidence of cuboid subluxation. Newell and Woodie also hypothesized that pronation allowed the peroneus longus to pull the lateral portion of the cuboid dorsally, causing the medial border to subluxate plantarward. In our experience, a cuboid has rarely been found in this position on physical examination. However, the peroneus longus may play a role in some cases. It becomes tight after a cuboid subluxation and should be relaxed with deep massage of the muscle belly before attempting reduction, which is difficult during peroneal spasm. Cuboid subluxation occurs more frequently in female dancers and is often of a different type than in male dancers. Generally, cuboid problems occur acutely in male dancers as they land (presumably pronating their foot and ankle) from one jump, or a series of big jumps, in a bravura variation. Female dancers, on the other hand, experience cuboid difficulties more often as part of an overuse syndrome. Anyone who has seen a ballerina bourr6 across the stage (move across the stage on full pointe) or perform 32 fouettes (rapid spinning movements combined with releves from foot-flat to full pointe) can appreciate the contributing factors to cuboid subluxation faced by the ballerina as she performs pointe work. Indeed, cuboid subluxation in female ballet dancers, and occasionally in male dancers, may be secondary to dorsal ligamentous laxity associated with hypermobility of the joints of the midfoot that is so frequently seen in dancers. This hypermobility may simply be the price paid by a dancer who has aesthetically pleasing, beautifully pointed feet (plantarflexion in slight valgus), or it may develop over time. We believe that a dancer moving from foot-flat to demipointe or full pointe initially places a dorsiflexion moment on the tarsometatarsal joints and joints of the midfoot. If the dancer goes past full pointe, as dancers with flexible feet often do, the forces are reversed and a plantarflexion moment is then in effect as she goes &dquo;over the top&dquo; and begins to dance on the dorsum of the toes and metatarsals. A dorsiflexion force returns as the dancer descends to full-foot contact with the floor. These repetitive force alterations may gradually decrease the stability of the midfoot, predis-
Management of a cuboid subluxation involves proper diagnosis, reduction of the subluxation, and maintenance of the reduction. The &dquo;cuboid whip&dquo; has been the standard technique for reducing the cuboid. It was described by Newell and Woodie (although not named as such) in 1981.~ Marshall’ described an adaptation of the technique, and called it the &dquo;cuboid squeeze.&dquo; He now describes the cuboid whip and squeeze as well as two previously unreported, effective techniques. Before attempting any of these techniques, the clinician must relax the long dorsal extensors and peronei with deep massage. The cuboid squeeze and cuboid whip are performed with the patient in the prone position. The clinician stands at the patient’s feet and holds the forefoot with his fingers while his thumbs are placed on the plantar surface of the cuboid. In the cuboid whip, the forefoot is then whipped into plantarflexion as the physician’s thumbs simultaneously
posing some dancers to cuboid-related difficulties. Cuboid subluxation can also be the sequelae of a traumatic sprain of the lateral foot. This is particularly true of a sprain involving the dorsal calcaneocuboid ligament and the dorsal cuboid-third, or cuboid-fourth, metatarsal ligament. Cuboid subluxations that occur secondary to such acute sprains must be managed carefully if one is to prevent a chronic condition from developing.
deliver a dorsally directed reduction force on the bottom of the cuboid. An alternate position has the patient prone and lying at table’s edge with the hip and knee flexed over the side of the table. In the cuboid squeeze, the clinician gradually stretches the foot and ankle into maximal plantarflexion. When the examiner feels the dorsal soft tissues relax, the cuboid is reduced with a final squeeze with the thumbs (Fig. 3). Our experience suggests that the cuboid squeeze is far more effective than the cuboid whip. The cuboid squeeze affords the therapist better control of the direction and intensity of the reduction force and, unlike the cuboid whip, none of the reduction force is absorbed by the dorsal soft tissues. An alternative technique effectively reduces cuboid subluxations and, with minor changes in hand placement and direction of the reduction force, is the treatment of choice for dorsal subluxations of the base of the fourth metatarsal. This technique can be performed with the patient supine
Figure 3. The correct position, hand placement, and direction of the reduction force for performing the cuboid squeeze.
172
and the examiner standing at the patient’s feet, and requires the clinician to &dquo;hang&dquo; the patient’s lower extremity by grasping the fourth metatarsal, thus allowing gravity and the weight of the leg to help distract the cuboid-fourth metatarsal joint. This distraction is critical to the success of the technique and requires the complete relaxation of the patient’s involved lower extremity. In cases where the cuboid is subluxated, the fourth metatarsal is then pulled in a longitudinal direction with the forefoot in slight plantarflexion (Fig. 4). Successful reductions are usually audible when performed in this manner. Dorsal subluxations of the base of the fourth metatarsal are reduced similarly. The clinician uses the same hand placement as pictured in Figure 4. The fourth metatarsalcuboid articulation is distracted by gravity as described previously. The final reduction force is produced with the second and third fingers by exerting a force in the plantar direction to the dorsal base of the fourth metatarsal, while simultaneously directing a dorsiflexion force with the thumbs to the plantar aspect of the head of the fourth metatarsal. Although the techniques we have described will result in successful reductions at least 90% of the time, additional methods are needed in recalcitrant cases. One such method has the patient supine and the therapist standing at the foot of the table. The forefoot is maximally everted on a neutrally positioned rearfoot and maintained by the therapist’s hand. The reduction force is delivered by the lateral aspect of the second metacarpal (Fig. 5). Frequently, the cuboid will reduce before the final pressure is delivered. Successful reduction is usually, but not always, audible and, in cases treated within 24 hours of onset, it produces immediate and complete resolution of pain and dysfunction. Individuals who have had a cuboid subluxated for long
Figure 5. The clinician reduces the cuboid using the lateral aspect of his or her second metacarpal. The forefoot is maximally pronated on a neutrally positioned rearfoot before
delivering a reduction force. periods
of time will experience a residual discomfort for days after the reduction. This depends on the severity and duration of the subluxation, although the feeling of weakness should disappear immediately. Individuals who have chronic subluxations fall into two categories: those who frequently and easily subluxate and likewise reduce with several
ease, and those who subluxate with less frequency, but whose reductions can be taxing. The &dquo;easy&dquo; group will usually have complete resolution of symptoms after reduction, while the
difficult group may complain of an ache for a day or important to realize that despite the type of subluxation present and reduction method employed, there is never any doubt in the mind of the patient if a complete reduction has occurred. A partial cessation of symptoms signals a partial reduction, and complete reduction should be attempted. Occasionally, attempts to reduce a subluxated cuboid will be unsuccessful. Repeated unsuccessful attempts are painful to the patient and should be avoided. In these cases, we recommend that the patient be treated with massage and ice and the reduction be attempted the following day. Whenever possible, the dancer should refrain from vigorous activity for a day or two after reduction to avoid a recurrent subluxation. However, when a day of rest is not possible, a 1/a-inch felt pad is placed beneath the cuboid on the plantar aspect of the foot, and secured using the taping method shown in Figure 6. This is recommended to maintain the reduction. To repeat this method, a 11/2- to 2-inch elastic adhesive tape should be used and placed directly on the skin for maximum stabilization. The dancer is supine on a table with his/her foot off the table edge. Begin by applying tape more
two. It is
I
Figure 4. The examiner &dquo;hangs&dquo; the patient’s injured foot by grasping the fourth metatarsal. Cuboids are reduced with a distraction force in the direction of the
arrow.
173
the cuboid squeeze is not recommended because the direction of the reduction force may cause further damage to traumatized tissues. Successful reduction should be maintained with felt and tape as described previously. A cuboid that subluxates recurrently may indicate that the joint capsule and ligaments have not healed adequately to maintain the reduction, and repeated reductions should be avoided. A minimum of 2 to 3 days before attempting another reduction is recommended. The management of chronic subluxations should include instruction in self-mobilization techniques; otherwise, a dependency can develop between the dancer and the physical therapist. The most successful self-mobilization techniques are shown in Figure 7. These techniques are particularly successful in individuals who reduce easily when the cuboid squeeze is performed. Dancer and therapist should only reduce chronically subluxating cuboids when absolutely necessary, as further laxity may develop that only exacerbates the problem. Acute lateral midfoot pain can be produced by conditions other than subluxation of the cuboid. Therefore, in cases where a cuboid subluxation is suspected but treatment is unsuccessful, other diagnoses should be considered: Unrecognized fracture or stress fracture. ~ Acute tendinitis of the peroneus longus or the os pero~
neum.
The sinus tarsi syndrome. 1, 10 Lateral process fracture of the talus.’ ~ Fracture or strain of the anterior process of the os calcis.3 Derangement of the lateral talocrural and subtalar joints. The meniscoid of the ankle.13 Further diagnostic studies should be performed as indicated. If severe pain is present and the patient cannot bear weight, obviously the foot should be examined for acute fracture before manipulation is performed. ~ ~
A minimal, three-piece taping method is used to maintain reduction of the cuboid subluxation. Begin taping from the medial aspect of the foot (A), and continue from the lateral aspect (B). The final step (C) secures the foot. (See text for details.) Reprinted with permission from Marshall P: The rehabiliation of overuse foot injuries in athletes and dancers. Clin Sports Med 7: 175-191, 1988.
Figure 6.
~
~
ILLUSTRATIVE CASES to the medial aspect of the foot, starting proximal to the first metatarsal head (Fig. 6A). Place the tape around the heel and then continue to the plantar aspect of the medial
longitudinal arch. Continue by encircling the rearfoot and midfoot twice. Figure 6B is similar, except that the tape is initiated from the lateral aspect of the foot. (For the sake of clarity, the previously applied tape is not shown.) Taping is secured with a final circumferential strip of tape (Fig. 6C), which should preferably be 3 inches in width. This taping also can be incorporated into a &dquo;J&dquo; strapping for greater control of the subtalar joint. Asking the dancer to releve five or six times following a successful reduction will help determine whether the reduction will be maintained. Cuboid subluxation following a second-degree or thirddegree lateral foot sprain calls for special care to prevent a chronic condition from developing. If a cuboid subluxation is suspected after a lateral foot sprain, the therapist should refrain from attempting a reduction until the effusion and ecchymosis have significantly diminished and the possibility of fracture has been ruled out. This usually occurs in 3 to 7 days. A gentle reduction can then be attempted; however,
Case1
A 38-year-old male principal dancer made a choreographed exit from the stage during the first act of Giselle. As soon as the wings were cleared, he exhibited an antalgic gait and reported the sudden onset of left lateral foot pain after landing from a jump while slightly off balance. He complained of left foot &dquo;weakness&dquo; and feared that he could not continue to perform. He was scheduled to return on stage in less than 5 minutes. A brief examination revealed a marked loss of plantar/dorsal excursion of the cuboid and palpation of the plantar aspect of the cuboid was sharply painful. He was positioned supine and the manipulation shown in Figure 4 was performed. An audible reduction occurred and the dancer reported immediate cessation of pain and dysfunction with normal weightbearing and releve. He returned to the stage as scheduled and performed without pain or discomfort. A felt pad and tape were applied at intermission to maintain the reduction. Five years after the incident, the dancer has not experienced another subluxation.
174
The cuboid was reduced, but subluxated again three times: 5, 8, and 20 days after the original reduction. Each time the cuboid was reduced successfully using the same technique, and taping was used to stabilize the midfoot and hindfoot. Five years after initial injury, the dancer has not experienced any cuboid difficulties.
Case 3 A 23-year-old female soloist presented with complaints of lateral left foot pain that prevented her from rehearsing or performing regularly. There was no trauma associated with the gradual onset of this pain, which persisted for 2 years in spite of treatment with physical therapy, nonsteroidal antiinflammatory medications, and multiple cortisone injections. An extensive workup had been negative. Physical examination revealed a complete loss of normal dorsoplantar glide in the left cuboid bone. Slight abduction of the left midfoot and forefoot was present when compared to the opposite foot. Trophic changes were seen over the dorsum of the area secondary to the multiple cortisone injections. The patient was treated daily with midtarsal joint adduction mobilizations (Fig. 2), along with rigorous attempts to return dorsoplantar motion to the cuboid. This motion was reestablished after 1 week and she was able to dance with less pain. The dancer was treated again 3 months later. During this period, marked improvement in cuboid mobility was achieved and several successful manipulations were performed (Fig. 5). The patient was instructed in self-mobilization (Fig. 7). Since that time, she has shown continued improvement, rarely experiences any significant cuboid-related discomfort, and has received several promotions in her ballet company.
CONCLUSIONS Cuboid-related subluxations
occur with consistent, signififrequency in high-level professional ballet dancers. With experience, the clinician can recognize and treat this syndrome. Management centers around the appropriate re-
cant
Figure 7. Self-mobilization techniques for cuboid subluxation. The dancer provides a reduction force via the cuboid squeeze (A) or by the base of a ballet barre (B). Case 2 A 27-year-old female soloist sprained her lateral left foot while in the demi-pointe position. Marked pain and effusion followed and the dancer was sent for orthopaedic evaluation. Radiographs taken at that time were normal and the dancer received daily physical therapy. Four days later, sharp pain persisted about the lateral foot and a bone scan was performed to rule out bone abnormality. The scan was normal. Two days later, enough effusion and ecchymosis had resolved to allow further examination. At this time, a cuboid subluxation was suspected, and a gentle reduction of the cuboid was performed using the method shown in Figure 5.
duction and maintenance of the cuboid or fourth metatarsal. Technique factors predisposing an individual to subluxations should also be addressed to avoid recurrence. Lastly, clinicians should recognize that the techniques discussed in this article can be adapted to reduce subluxations of other tarsometatarsal articulations. Although much of our study is based on anecdotal evidence, the findings suggest a distinct clinical entity. Other conditions, such as subluxations of the glenohumeral joint and tarsometatarsal joints, are diagnoses that must be based on the history and physical examination alone. As the cuboid subluxation becomes better recognized and therapists are more aware of the problem, perhaps reliable methods of documentation or confirmation can be found.
175
ACKNOWLEDGMENT The authors thank Gary Giffune, a member of Ballet Arizona, for the illustrations in this manuscript.
REFERENCES 1
Bernstein RH, Bartolomei FJ, McCarthy DJ: The sinus tarsi syndrome: Anatomical, clinical, and surgical considerations. J Am Podiatr Med Assoc
5. Hiss JM: Establishing a foot practice. J Am Osteopath Assoc 27. 536-541, 1928 6. Hiss JM Functional Foot Disorders Los Angeles, The Oxford Press, 1949, pp 295-322 7. Jobe F: Diagnoses and nonoperatme treatment of shoulder injuries in athletes Clin Sports Med 8. 419-438, 1989 8. Newell SG, Woodie A: Cuboid syndrome. Physician Sportsmed 9(4) 71-
76, 1981 9. Marshall P. The rehabilitation of overuse foot injuries in athletes and dancers Clin Sports Med 7(1): 175-191, 1988 10. Taillard W, Meyer JM, Garcia J, et al: The sinus tarsi syndrome int Orthop
: 117-130, 1981 5
75: 475-480, 1985 2 Blakeslee TJ, Morris JL Cuboid syndrome and the significance of midtarsal joint stability. J Am Podiatr Med Assoc 77: 638-640, 1987 3 Harburn T, Ross H: Avulsion fracture of the anterior calcaneal process.
Physician Sportsmed 15(4) 73-80, 1987 4 Hawkins LG Fracture of the lateral process of the talus. J Bone Joint Surg 47A: 1170-1175, 1965
Taplin GC: Foot technique. J Am Osteopath Assoc 27: 606-608, 1928 Thompson FM, Hamilton WG: Problems of the second metatarsophalangeal joint Orthopedics 10. 83-89, 1987 13. Wolin I, Glassman F, Sideman S, et al: Internal derangement of the talofibular component of the ankle Surg Gynecol Obstet 91: 193-200, 11. 12.
1950
From the American Ballet Theater, New York, New York
ABSTRACT
cuboid will usually yield excellent and often dramatic results in the management of this commonly overlooked affliction. A dancer (or athlete) with a cuboid subluxation will complain of lateral foot pain and weakness in push-off. The pain often radiates to the plantar aspect of the medial foot, the anterior ankle joint, or distally along the fourth ray. The dancer usually feels an inability to &dquo;work through the foot,&dquo; while moving from foot-flat to demi-pointe or full pointe. Dancing vigorously and jumping are usually impossible because of localized, sharp pain. Pressing dorsalward on the plantar surface of the cuboid is painful. The cuboid’s minimal dorsal/plantar joint play is markedly reduced or absent when compared to the uninvolved foot. Severely subluxated cuboids sometimes leave a shallow, visible depression on the dorsum of the cuboid and a fullness on the plantar aspect. Unfortunately, repeated attempts to document or confirm the diagnosis by radiographs, computerized axial tomography (CT) scans, or magnetic resonance imaging (MRI) studies have been unsuccessful because of normal variations between the cuboid and its surrounding structures. Other authors agree that this is probably caused by the minimal amount of subluxation that is present Indeed, the term &dquo;locked cuboid,&dquo; used by Hiss5 s may more accurately describe this condition. This term suggests a small subluxation that markedly reduces the normal motion in the midtarsal (Chopart’s) joint, altering the normal mechanics and the relationship between the hindfoot and forefoot. Other well-known and well-accepted conditions such as subluxations of the shoulder’ and metatarsophalangeal joints of the foot&dquo; cannot be documented on radiographs and the diagnosis must be made on the basis of the patient’s history and physical examination. Occasionally, the fourth metatarsal may subluxate on the cuboid. These subluxations can be easily mistaken for plantar subluxations of the cuboid, because the base of the fourth metatarsal almost always moves dorsally in the dancers we have seen. This diagnosis is aided by the fact that a subluxated metatarsal acts like a log floating in the water-when one end rises, the other end sinks. Thus, when the base of the fourth metatarsal subluxates dorsally on the cuboid, the head of the metatarsal will be plantarflexed (&dquo;dropped&dquo;) when compared to the adjacent metatarsals and the fourth
Cuboid subluxation is a common but poorly recognized condition. Its symptoms include lateral midfoot pain and an inability to "work through the foot." In addition, pressing on the plantar surface of the cuboid in a dorsal direction produces pain. The normal dorsal/plantar joint play is reduced or absent when compared to the uninjured side, and subtle forefoot valgus is present. Frequently, there is a shallow depression on the dorsal surface of the foot and palpable fullness on the plantar aspect of the cuboid. Documentation by radiograph, CT scan, or magnetic resonance imaging is difficult because of the normal variations found in the relationship between the cuboid and its surrounding structures. The diagnosis is primarily subjective, and must be made on the basis of the patient’s history and physical findings. Treatment requires recognition of the condition, manual reduction by a therapist or physician familiar with the condition, and followup to be certain that the cuboid remains in place. Therapists and orthopaedists involved in the care of dancers should be alert to the possibility of cuboid subluxation and be able to recognize it when it occurs.
spite of the scarcity of information in the medical literaon cuboid subluxation,’ experience with professional ballet dancers suggests that this is a common but poorly recognized affliction.’ We report the incidence of cuboid In
ture
subluxation in American Ballet Theater,
one
of America’s
premier international ballet companies. The characteristic symptoms, physical findings, and theories regarding its cause are presented, as well as a variety of manual therapeutic techniques that reduce the subluxated cuboid and subluxation of the fourth metatarsal on the cuboid. When the to this syndrome, it can be easily recognized. Patience and practice in manual reduction of the
physician is alert
*
Address
correspondence and repnnt requests
to Peter Marshall, MA, PT,
Physical Therapist, Baryshnikov Productions and The White Oak Dance Project, 111 East 14th Street, Suite 385, New York, NY 10003.
169
170
metatarsal of the uninvolved foot (Fig. 1). Dancers with dorsal subluxations of the base of the fourth metatarsal present with the same symptoms as dancers with plantar subluxation of the cuboid. They are also predisposed to capsular irritation (&dquo;stone bruises&dquo;) of the plantar aspect of the head of the prominent fourth metatarsal. Most professional female ballet dancers have dorsal callosities (&dquo;toe shoe knots&dquo;) over the dorsum of the metatarsal heads. Thus, the absence of a callus over the fourth metatarsal head indicates that the fourth metatarsal has been in plantarflexion for some time and may be a normal condition for that particular dancer, especially if she has the same configuration in the other foot. This finding alone does not necessarily rule out an acute dorsal subluxation of the base of the fourth metatarsal, but it greatly diminishes its prob-
ability. Abduction of the forefoot at the midtarsal joints predisposes an individual to plantar cuboid subluxation.&dquo; Careful inspection of the relative position of the forefoot to the hindfoot will often reveal a subtle midfoot abduction when the cuboid subluxates, in comparison to the uninvolved foot. The abducted position of the foot must be corrected or diminished to facilitate and maintain reduction of the cuboid (Fig. 2). The tendency for ballet dancers to seek the valgus position of the forefoot when on releve may predispose them to cuboid subluxation. Cuboid subluxation secondary to a sprain of the lateral foot or ankle is more difficult to detect because it is easy for the clinician to assume that the dancer’s complaints are
Figure 2. To realign an abducted midtarsal joint, the patient’s foot is positioned between the clinician’s knees, the medial foot is contacted at the distal talus and the lateral foot at the lateral aspect of the cuboid, and an adduction force is then applied by the clinician’s hand and knees. TABLE 1
Incidence of cuboid
injuries in professional dancers
because of injured soft tissues. Effusion and ecchymosis make determination of the cuboid’s joint play, or visible detection of a shallow depression, difficult. While pressing dorsalward on the plantar aspect of the cuboid may be uncomfortable to anyone with a sprain of the lateral foot, it causes severe pain in someone who has sustained a cuboid subluxation accompanying such a sprain. Lingering symptoms and disability may indicate that cuboid subluxation has occurred along with the injury. Incidence
Figure
1. The
&dquo;dropped&dquo; fourth metatarsal head.
The records of all injuries requiring physical therapy treatments in the American Ballet Theater were reviewed during two separate 3-week periods to examine the incidence of cuboid subluxations during both performance and rehearsal schedules. The records examined were from a 3-week performance season in Los Angeles during March 1986 and from a 3-week rehearsal schedule in New York City during January 1987. Cuboid subluxations totaled over 17% of foot and ankle injuries during these two periods (Table 1). There were no significant differences between the performance and the rehearsal schedules. Newell and Woodie’ reviewed the records of 3600 athletes with foot injuries and found that 4% of their symptoms came from the region of the cuboid bone. The incidence of cuboidrelated difficulties appears to be higher in professional dancers than in other athletes. This disparity is presumably due to the technical and aesthetic demands of ballet.
171
Etiology
Treatment
While Newell and Woodie8 found that 80% of cuboid subluxations in athletes occurred in pronated feet, we have not found this to be true in dancers. We found that cuboid subluxation occurred in all foot types, including cavus feet (the most desirable in ballet). A cavus forefoot can still pronate in relation to the hindfoot, and the dancers who pronate (usually to compensate for deficiencies in turnout from the hip and knee) appear to have an increased incidence of cuboid subluxation. Newell and Woodie also hypothesized that pronation allowed the peroneus longus to pull the lateral portion of the cuboid dorsally, causing the medial border to subluxate plantarward. In our experience, a cuboid has rarely been found in this position on physical examination. However, the peroneus longus may play a role in some cases. It becomes tight after a cuboid subluxation and should be relaxed with deep massage of the muscle belly before attempting reduction, which is difficult during peroneal spasm. Cuboid subluxation occurs more frequently in female dancers and is often of a different type than in male dancers. Generally, cuboid problems occur acutely in male dancers as they land (presumably pronating their foot and ankle) from one jump, or a series of big jumps, in a bravura variation. Female dancers, on the other hand, experience cuboid difficulties more often as part of an overuse syndrome. Anyone who has seen a ballerina bourr6 across the stage (move across the stage on full pointe) or perform 32 fouettes (rapid spinning movements combined with releves from foot-flat to full pointe) can appreciate the contributing factors to cuboid subluxation faced by the ballerina as she performs pointe work. Indeed, cuboid subluxation in female ballet dancers, and occasionally in male dancers, may be secondary to dorsal ligamentous laxity associated with hypermobility of the joints of the midfoot that is so frequently seen in dancers. This hypermobility may simply be the price paid by a dancer who has aesthetically pleasing, beautifully pointed feet (plantarflexion in slight valgus), or it may develop over time. We believe that a dancer moving from foot-flat to demipointe or full pointe initially places a dorsiflexion moment on the tarsometatarsal joints and joints of the midfoot. If the dancer goes past full pointe, as dancers with flexible feet often do, the forces are reversed and a plantarflexion moment is then in effect as she goes &dquo;over the top&dquo; and begins to dance on the dorsum of the toes and metatarsals. A dorsiflexion force returns as the dancer descends to full-foot contact with the floor. These repetitive force alterations may gradually decrease the stability of the midfoot, predis-
Management of a cuboid subluxation involves proper diagnosis, reduction of the subluxation, and maintenance of the reduction. The &dquo;cuboid whip&dquo; has been the standard technique for reducing the cuboid. It was described by Newell and Woodie (although not named as such) in 1981.~ Marshall’ described an adaptation of the technique, and called it the &dquo;cuboid squeeze.&dquo; He now describes the cuboid whip and squeeze as well as two previously unreported, effective techniques. Before attempting any of these techniques, the clinician must relax the long dorsal extensors and peronei with deep massage. The cuboid squeeze and cuboid whip are performed with the patient in the prone position. The clinician stands at the patient’s feet and holds the forefoot with his fingers while his thumbs are placed on the plantar surface of the cuboid. In the cuboid whip, the forefoot is then whipped into plantarflexion as the physician’s thumbs simultaneously
posing some dancers to cuboid-related difficulties. Cuboid subluxation can also be the sequelae of a traumatic sprain of the lateral foot. This is particularly true of a sprain involving the dorsal calcaneocuboid ligament and the dorsal cuboid-third, or cuboid-fourth, metatarsal ligament. Cuboid subluxations that occur secondary to such acute sprains must be managed carefully if one is to prevent a chronic condition from developing.
deliver a dorsally directed reduction force on the bottom of the cuboid. An alternate position has the patient prone and lying at table’s edge with the hip and knee flexed over the side of the table. In the cuboid squeeze, the clinician gradually stretches the foot and ankle into maximal plantarflexion. When the examiner feels the dorsal soft tissues relax, the cuboid is reduced with a final squeeze with the thumbs (Fig. 3). Our experience suggests that the cuboid squeeze is far more effective than the cuboid whip. The cuboid squeeze affords the therapist better control of the direction and intensity of the reduction force and, unlike the cuboid whip, none of the reduction force is absorbed by the dorsal soft tissues. An alternative technique effectively reduces cuboid subluxations and, with minor changes in hand placement and direction of the reduction force, is the treatment of choice for dorsal subluxations of the base of the fourth metatarsal. This technique can be performed with the patient supine
Figure 3. The correct position, hand placement, and direction of the reduction force for performing the cuboid squeeze.
172
and the examiner standing at the patient’s feet, and requires the clinician to &dquo;hang&dquo; the patient’s lower extremity by grasping the fourth metatarsal, thus allowing gravity and the weight of the leg to help distract the cuboid-fourth metatarsal joint. This distraction is critical to the success of the technique and requires the complete relaxation of the patient’s involved lower extremity. In cases where the cuboid is subluxated, the fourth metatarsal is then pulled in a longitudinal direction with the forefoot in slight plantarflexion (Fig. 4). Successful reductions are usually audible when performed in this manner. Dorsal subluxations of the base of the fourth metatarsal are reduced similarly. The clinician uses the same hand placement as pictured in Figure 4. The fourth metatarsalcuboid articulation is distracted by gravity as described previously. The final reduction force is produced with the second and third fingers by exerting a force in the plantar direction to the dorsal base of the fourth metatarsal, while simultaneously directing a dorsiflexion force with the thumbs to the plantar aspect of the head of the fourth metatarsal. Although the techniques we have described will result in successful reductions at least 90% of the time, additional methods are needed in recalcitrant cases. One such method has the patient supine and the therapist standing at the foot of the table. The forefoot is maximally everted on a neutrally positioned rearfoot and maintained by the therapist’s hand. The reduction force is delivered by the lateral aspect of the second metacarpal (Fig. 5). Frequently, the cuboid will reduce before the final pressure is delivered. Successful reduction is usually, but not always, audible and, in cases treated within 24 hours of onset, it produces immediate and complete resolution of pain and dysfunction. Individuals who have had a cuboid subluxated for long
Figure 5. The clinician reduces the cuboid using the lateral aspect of his or her second metacarpal. The forefoot is maximally pronated on a neutrally positioned rearfoot before
delivering a reduction force. periods
of time will experience a residual discomfort for days after the reduction. This depends on the severity and duration of the subluxation, although the feeling of weakness should disappear immediately. Individuals who have chronic subluxations fall into two categories: those who frequently and easily subluxate and likewise reduce with several
ease, and those who subluxate with less frequency, but whose reductions can be taxing. The &dquo;easy&dquo; group will usually have complete resolution of symptoms after reduction, while the
difficult group may complain of an ache for a day or important to realize that despite the type of subluxation present and reduction method employed, there is never any doubt in the mind of the patient if a complete reduction has occurred. A partial cessation of symptoms signals a partial reduction, and complete reduction should be attempted. Occasionally, attempts to reduce a subluxated cuboid will be unsuccessful. Repeated unsuccessful attempts are painful to the patient and should be avoided. In these cases, we recommend that the patient be treated with massage and ice and the reduction be attempted the following day. Whenever possible, the dancer should refrain from vigorous activity for a day or two after reduction to avoid a recurrent subluxation. However, when a day of rest is not possible, a 1/a-inch felt pad is placed beneath the cuboid on the plantar aspect of the foot, and secured using the taping method shown in Figure 6. This is recommended to maintain the reduction. To repeat this method, a 11/2- to 2-inch elastic adhesive tape should be used and placed directly on the skin for maximum stabilization. The dancer is supine on a table with his/her foot off the table edge. Begin by applying tape more
two. It is
I
Figure 4. The examiner &dquo;hangs&dquo; the patient’s injured foot by grasping the fourth metatarsal. Cuboids are reduced with a distraction force in the direction of the
arrow.
173
the cuboid squeeze is not recommended because the direction of the reduction force may cause further damage to traumatized tissues. Successful reduction should be maintained with felt and tape as described previously. A cuboid that subluxates recurrently may indicate that the joint capsule and ligaments have not healed adequately to maintain the reduction, and repeated reductions should be avoided. A minimum of 2 to 3 days before attempting another reduction is recommended. The management of chronic subluxations should include instruction in self-mobilization techniques; otherwise, a dependency can develop between the dancer and the physical therapist. The most successful self-mobilization techniques are shown in Figure 7. These techniques are particularly successful in individuals who reduce easily when the cuboid squeeze is performed. Dancer and therapist should only reduce chronically subluxating cuboids when absolutely necessary, as further laxity may develop that only exacerbates the problem. Acute lateral midfoot pain can be produced by conditions other than subluxation of the cuboid. Therefore, in cases where a cuboid subluxation is suspected but treatment is unsuccessful, other diagnoses should be considered: Unrecognized fracture or stress fracture. ~ Acute tendinitis of the peroneus longus or the os pero~
neum.
The sinus tarsi syndrome. 1, 10 Lateral process fracture of the talus.’ ~ Fracture or strain of the anterior process of the os calcis.3 Derangement of the lateral talocrural and subtalar joints. The meniscoid of the ankle.13 Further diagnostic studies should be performed as indicated. If severe pain is present and the patient cannot bear weight, obviously the foot should be examined for acute fracture before manipulation is performed. ~ ~
A minimal, three-piece taping method is used to maintain reduction of the cuboid subluxation. Begin taping from the medial aspect of the foot (A), and continue from the lateral aspect (B). The final step (C) secures the foot. (See text for details.) Reprinted with permission from Marshall P: The rehabiliation of overuse foot injuries in athletes and dancers. Clin Sports Med 7: 175-191, 1988.
Figure 6.
~
~
ILLUSTRATIVE CASES to the medial aspect of the foot, starting proximal to the first metatarsal head (Fig. 6A). Place the tape around the heel and then continue to the plantar aspect of the medial
longitudinal arch. Continue by encircling the rearfoot and midfoot twice. Figure 6B is similar, except that the tape is initiated from the lateral aspect of the foot. (For the sake of clarity, the previously applied tape is not shown.) Taping is secured with a final circumferential strip of tape (Fig. 6C), which should preferably be 3 inches in width. This taping also can be incorporated into a &dquo;J&dquo; strapping for greater control of the subtalar joint. Asking the dancer to releve five or six times following a successful reduction will help determine whether the reduction will be maintained. Cuboid subluxation following a second-degree or thirddegree lateral foot sprain calls for special care to prevent a chronic condition from developing. If a cuboid subluxation is suspected after a lateral foot sprain, the therapist should refrain from attempting a reduction until the effusion and ecchymosis have significantly diminished and the possibility of fracture has been ruled out. This usually occurs in 3 to 7 days. A gentle reduction can then be attempted; however,
Case1
A 38-year-old male principal dancer made a choreographed exit from the stage during the first act of Giselle. As soon as the wings were cleared, he exhibited an antalgic gait and reported the sudden onset of left lateral foot pain after landing from a jump while slightly off balance. He complained of left foot &dquo;weakness&dquo; and feared that he could not continue to perform. He was scheduled to return on stage in less than 5 minutes. A brief examination revealed a marked loss of plantar/dorsal excursion of the cuboid and palpation of the plantar aspect of the cuboid was sharply painful. He was positioned supine and the manipulation shown in Figure 4 was performed. An audible reduction occurred and the dancer reported immediate cessation of pain and dysfunction with normal weightbearing and releve. He returned to the stage as scheduled and performed without pain or discomfort. A felt pad and tape were applied at intermission to maintain the reduction. Five years after the incident, the dancer has not experienced another subluxation.
174
The cuboid was reduced, but subluxated again three times: 5, 8, and 20 days after the original reduction. Each time the cuboid was reduced successfully using the same technique, and taping was used to stabilize the midfoot and hindfoot. Five years after initial injury, the dancer has not experienced any cuboid difficulties.
Case 3 A 23-year-old female soloist presented with complaints of lateral left foot pain that prevented her from rehearsing or performing regularly. There was no trauma associated with the gradual onset of this pain, which persisted for 2 years in spite of treatment with physical therapy, nonsteroidal antiinflammatory medications, and multiple cortisone injections. An extensive workup had been negative. Physical examination revealed a complete loss of normal dorsoplantar glide in the left cuboid bone. Slight abduction of the left midfoot and forefoot was present when compared to the opposite foot. Trophic changes were seen over the dorsum of the area secondary to the multiple cortisone injections. The patient was treated daily with midtarsal joint adduction mobilizations (Fig. 2), along with rigorous attempts to return dorsoplantar motion to the cuboid. This motion was reestablished after 1 week and she was able to dance with less pain. The dancer was treated again 3 months later. During this period, marked improvement in cuboid mobility was achieved and several successful manipulations were performed (Fig. 5). The patient was instructed in self-mobilization (Fig. 7). Since that time, she has shown continued improvement, rarely experiences any significant cuboid-related discomfort, and has received several promotions in her ballet company.
CONCLUSIONS Cuboid-related subluxations
occur with consistent, signififrequency in high-level professional ballet dancers. With experience, the clinician can recognize and treat this syndrome. Management centers around the appropriate re-
cant
Figure 7. Self-mobilization techniques for cuboid subluxation. The dancer provides a reduction force via the cuboid squeeze (A) or by the base of a ballet barre (B). Case 2 A 27-year-old female soloist sprained her lateral left foot while in the demi-pointe position. Marked pain and effusion followed and the dancer was sent for orthopaedic evaluation. Radiographs taken at that time were normal and the dancer received daily physical therapy. Four days later, sharp pain persisted about the lateral foot and a bone scan was performed to rule out bone abnormality. The scan was normal. Two days later, enough effusion and ecchymosis had resolved to allow further examination. At this time, a cuboid subluxation was suspected, and a gentle reduction of the cuboid was performed using the method shown in Figure 5.
duction and maintenance of the cuboid or fourth metatarsal. Technique factors predisposing an individual to subluxations should also be addressed to avoid recurrence. Lastly, clinicians should recognize that the techniques discussed in this article can be adapted to reduce subluxations of other tarsometatarsal articulations. Although much of our study is based on anecdotal evidence, the findings suggest a distinct clinical entity. Other conditions, such as subluxations of the glenohumeral joint and tarsometatarsal joints, are diagnoses that must be based on the history and physical examination alone. As the cuboid subluxation becomes better recognized and therapists are more aware of the problem, perhaps reliable methods of documentation or confirmation can be found.
175
ACKNOWLEDGMENT The authors thank Gary Giffune, a member of Ballet Arizona, for the illustrations in this manuscript.
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Bernstein RH, Bartolomei FJ, McCarthy DJ: The sinus tarsi syndrome: Anatomical, clinical, and surgical considerations. J Am Podiatr Med Assoc
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: 117-130, 1981 5
75: 475-480, 1985 2 Blakeslee TJ, Morris JL Cuboid syndrome and the significance of midtarsal joint stability. J Am Podiatr Med Assoc 77: 638-640, 1987 3 Harburn T, Ross H: Avulsion fracture of the anterior calcaneal process.
Physician Sportsmed 15(4) 73-80, 1987 4 Hawkins LG Fracture of the lateral process of the talus. J Bone Joint Surg 47A: 1170-1175, 1965
Taplin GC: Foot technique. J Am Osteopath Assoc 27: 606-608, 1928 Thompson FM, Hamilton WG: Problems of the second metatarsophalangeal joint Orthopedics 10. 83-89, 1987 13. Wolin I, Glassman F, Sideman S, et al: Internal derangement of the talofibular component of the ankle Surg Gynecol Obstet 91: 193-200, 11. 12.
1950
